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Preoperative

preparationHow to reduce anxiety?

Lonneke Staals

Erasmus MC-Sophia

Rotterdam

l.staals@erasmusmc.nl

How to reduce preoperative anxiety?

• Consequences of anxiety

• Sedative premedication

• Nonpharmacological interventions

Anxiety

• Distress highest during

induction of anesthesia

• 60% of children report

significant anxiety

Kain ZN, Paediatr Anaesth 2006

Anxiety results

• Postoperative• Higher postoperative pain

• Delayed hospital discharge

• More analgesics need

• Higher incidence of emergence delirium

• Sleep disturbances (nightmares)

• Long-term• Maladaptive behavioral changes (nocturnal enuresis, separation

anxiety)

• PTSD

Fortier MA, Paediatr Anaesth 2015; Kain ZN, Anesth Analg 2004;Ben-Amitay G, J Paed Child Health 2006

Anxiety results

• Lowers pain thresholds

• Facilitates overestimation of pain intensity

• Results in increased postoperative pain

Kain ZN, Paediatr Anaesth 2006

Parental anxiety

• Strongly related to

child preoperative anxiety

and postoperative pain

• High parental anxiety: related to development of postopmaladaptive behavior changes in children

• Reduced parental anxiety: decreases preop anxiety in children

Shirley P, Anaesthesia 1998; Fortier MA, Paediatr Anaesth 2010

Preoperative period

• Pre-anesthetic visit• Beneficial anxiolytic effect

• Preop discussion and reassurances: reduces postop pain

• Holding area• Time spent waiting in the holding = one of the most frightening

events in the perioperative period

• Should be kept as short as possible!

Preoperative preparation programs

• Support of a psychologist throughout the surgical episode is helpful

• Preop preparations programs (group lectures, written material, films, OR tours)

• Limitations:• High operational costs• Parents and child need time to attend• Programs are generic (do not address variantions across individuals)• Do not enhance coping skills• Prepare for the “overall” process, not on for example pain

specifically• Mostly not geared toward parents

Cuzzocrea F, Paediatr Anaesth 2013

Preop preparation programs

• Accessible• Internet

• Tailored, based upon individual characteristics of childrenand parents• Age, temperament• Parental trait anxiety• Type of surgery

• Inexpensive / low operational costs for het hospital• Most effective = coping skills training• Also focus on pain management

• Parental pain management attitudes

Fortier MA, Paediatr Anaesth 2015

Nonpharmacological interventions

• Low sensory environment• Improved cooperation at induction

• Hypnosis• Non-significant trend towards reduced anxiety during induction

compared with midazolam

Yip P, 2009, Cochrane Database Syst Review; Kain ZN, Anesth Analg 2001

Helping children cope

• The power of suggestion (good or bad!)• Human nature is geared to choose the more negative interpretation

• Children take things literally!

• “nocebo” effects

• Be aware of negative suggestions• Little sting

• It will hurt a bit

Lang EV, J Radiol Nurs 2017; 36: 44-50

Do’s and Dont’s

• Avoid mentioning pain• Adapt to the patient’s body position• Avoidance of “try”• Children’s suggestibility

• Scenario’s (hobby, sport)

• Developmental stage• Leaving children choices as to what

will happen

Parental presence

• No significant differences in

anxiety or cooperation during

induction

• 1 trial: significantly less effective than the use of midazolam

• In parents receiving acupuncture: children less anxiousduring induction

Yip P, Cochrane Database Syst Rev 2009; Wang SM, Anesthesiology 2004

Music

• Reduces pain, stress and morfine use

• Distraction of negative stimuli

• Effect on autonomous nervous system• endorphines

• Reduces release of catecholamines and

cortisol

• No significant positive effect on

preop anxiety

Bradt J, Cochrane Database Syst Rev 2013; vd Heijden MJE, PLoS 2015, Fancourt D, Brain Behav Immun 2014; Kühlmann AYR, Anesth Analg 2019

Video games

• Computer program

• Video games• Better cooperation than having

parents present

• Significant positive effect on anxiety

compared to no intervention or

premedication

Campbell C, Ped Anesth 2005; Patel A, Ped Anesth 2006

VR as distraction

Eijlers R, Anesth Analg 2019

VR tour of the OR

• 70 children, age 4-10 years, ASA I & II

• RCT: 35 CAU (information) vs 35 VR tour (4 min 360°movie)

• Main outcome: mYPAS before entering the OR

• ICC (induction compliance checklist) during induction

VR tour of the OR

• 1 child dizzy from VR

• Median age 6 years

• Comparable groups

Ryu J-H, British Journal of Surgery 2017

Goal 1/ Anxiety during induction2/ Postop pain, anxiety, rescueanalgesia, emergence delirium3/ Predictors of VRE efficacy

Group200 children (4-12 years) in daycare (ASA I & II)Elective ENT / maxillofacial/ dental surgeryMarch 2017 – October 2018

Eijlers R, Eur J Anaesthesiol 2019

DesignRandomized Controlled Trial

Primary outcome (T3)• Child anxiety at induction(mYPAS)

T2

Afterintervention

T4

Recovery

T3

InductionAnesthesia

T5

At home

T1

Admission

Secondary outcomes (T2-T5)• Child anxiety (mYPAS, VAS)• Parental anxiety (VAS, STAI)• Pain (faces pain scale, FLACC)• Emergence delirium (PAED)• Analgesics and health care use (at

home: PPPM)

Main predictors (T1)• Psychopathology child (CBCL)• Parental anxiety (STAI, VAS)• Child anxiety (mYPAS, STAIC,

VAS)

Eijlers R, Eur J Anaesthesiol 2019

PREVIEW study

• Standard anesthesia protocol• Propofol / fentanyl or sevoflurane induction.

• Sevo / fentanyl maintenance.

• Paracetamol IV and diclofenac IV.

• If needed morphine 0,1 mg/kg IV

• Rescue analgesia at the recovery ward: morphine

• Standard postop: paracetamol and diclofenac

Results PREVIEW

• 200 children enrolled (100 VRE and 100 CAU)

• Analysis in 191 participants (94 VRE and 97 CAU)• Age (median): VRE 8,3 / CAU 7,5

• 21 VRE children discontinued (median age 5,0 years old)

Results PREVIEW

• mYPAS scores were similar in CAU and VRE

• Self reported VAS scores for anxiety also comparable

• Preop parental state anxiety was significant predictor

• No differences in pain levels (FPS-r, FLACC or PPPM)

• No differences in emergence delirium symptoms

• Rescue analgesia: after adenoidectomy / TE:

VRE group needed significantly less morphine (55% of children, compared to CAU 95,7% of children)

PREVIEW

• VRE more effective prior to more extensive surgery?

• More time needed between VRE and surgery?

• Multiple sessions needed?

• Not mYPAS but rather compliance (ICC)?

• No difference because routine CAU is already effective?

Conclusion

• 60% of children report significant anxiety during induction

• Parental anxiety strongly related to child anxiety

• Preop preparations programs should be geared towardschild and parent

• Tailored towards age, personality and type of procedure

• Distraction may help

• Preoperative exposure therapy or coping skills training maybe better